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Infertility

Diagnosis and Management

Infertility is defined as the inability to conceive or carry a pregnancy to term. About 1 in 10 women in the Western population have difficulty either becoming pregnant or carrying a pregnancy to term. According to a recent survey, approximately 11% of women of childbearing age in the United States are unable to conceive.

Although infertility is often considered a female problem, male infertility is also quite common. Male infertility is either the sole cause or a contributing factor in approximately 40% of infertile couples. Thus, the male and female partner both need to be thoroughly evaluated before a diagnosis can be made.

Most clinicians define infertility as the inability to become pregnant after 1 year of engaging in regular intercourse without using contraceptives. This time frame may be reasonable for a couple in their 20s. However, a couple in their mid to late 30s may not have the luxury of waiting a year. For example, a woman may try for years to become pregnant naturally, only to discover that her ovarian reserve has been depleted by the time she seeks help. Thus, a woman who delays fertility treatment may no longer be able to use her own eggs. Although IVF treatments can be performed using donor eggs or donor embryos, consulting a fertility specialist in a timely manner can help avoid the additional financial burden and wait times of donor matching.

Couples who have never been able to conceive are considered to have primary infertility. Conversely, secondary infertility describes couples who previously conceived with- out any assistance but are no longer able to conceive naturally. There are a number of causes of secondary infertility, including parental age, premature menopause, a history of radiation and/or chemotherapy, surgical complications, and a poor diet. Fortunately, most couples with secondary infertility can usually achieve pregnancy under the right conditions.

Assuming that both the male and the female partner* are still within the normal age of fertility†, there are several causes of secondary infertility that must first be ruled out. As with any infertility workup, a careful medical history can offer valuable insights into possible causes and is key to establishing the right treatment plan. We have found in our own clinical experience that varicocele (enlarged veins within the man’s scrotum) is a very common cause of secondary infertility. Overall, varicocele is the most common cause of secondary male infertility.

Premature ovarian failure and hostile uterine conditions are the two main causes of secondary infertility in women. Hostile uterine conditions may be due to previous surgery, a fibroid or polyp, advanced stage endometriosis, or other conditions that can interfere with pregnancy. Thus, women suffering from secondary infertility will likely undergo the same hormone tests used to evaluate women with primary infertility plus additional studies, such as a hysterosalpingogram (an x-ray image of the uterus and fallopian tubes), to assess the uterine conditions.

Primary infertility may be due to a single cause or multiple causes. The first step in evaluating a couple with primary infertility is hormone testing, a pelvic ultrasound for the woman, and sperm analysis for the man. At this point, couples must decide whether to undergo a more thorough infertility evaluation or begin treatment after the initial assessment. Although most fertility specialists prefer to make a diagnosis before beginning treatment, many patients opt to begin treatment after the initial evaluation. This is primarily because a thorough infertility workup can cost three to four times as much as an IVF treatment. Thus, many couples will only opt for a thorough workup after at least one IVF treatment has failed.

An IVF cycle is both an emotional and financial investment for patients, and failure can be disappointing and even traumatic. However, a negative IVF outcome can provide useful insights for the fertility specialist including informa- tion regarding the woman’s ovarian response to ovulation induction, the quality of oocytes obtained after ovulation induction, the fertilization potential of the oocytes, the fertil- ization capacity of the sperm, and the quality of the resulting embryos. With this information in hand, a fertility special- ist can make a more informed decision about how best to proceed. Fertility treatments are very patient-specific, and information obtained from a failed IVF cycle can be used to develop a more customized treatment plan.

*We refer to couples as male and female in the reproductive sense, not to be discriminatory. We welcome both heterosexual and same-sex couples at our IVF unit.

† Although using age as an indicator of fertility is not ideal, it may serve as an appropriate indicator of the inability to conceive. For example, a woman who had a child at the age of 30 but cannot have a child at the age of 50 would not be diagnosed with secondary infertility.

On our website, you will find links to the pages that will direct you to factors causing female infertility, factors causing male infertility, how infertility assessment can be made as well as how to identify the right treatment method for your unique condition. For any queries you may have about any of these subjects, please use our contact form to contact us with your questions and we will be happy to answer.